CAGABCAB, MELANY C.

BSN2

Leopold’s Maneuver

PROCEDURE TO BE PERFORMED: LEOPOLD’S MANEUVER

DEFINITION OF THE PROCEDURE: a systematic method of observation and palpation to determine the fetal
presentation and position and are done as part physical examination.

PURPOSES OF THE PROCEDURE:

 To determine the presentation of the fetus and age.
 To detect any abnormality of the abdominal organs
 To confirm pregnancy
 To estimate the period of gestation
 To detect any deviation from normal

EQUIPMENTS TO BE USED IN THE PROCEDURE:

 Tape measure
 Stethoscope/doppler
 Pinard fetoscope or sonic fetal heart sound device
 Client record

Leopold’s Maneuver Rationale 5 4 3 2 1

1. Explain the procedure to the

Providing information fosters cooperation
patient.

2. Let patient empty her

For adequate, readiness and ease of procedure
bladder.

3. Screen To provide privacy

4. Place the patient in supine

position with knees slightly To promote comfort
flexed.

To promote comfort and warmth and avoid transmission

5. Warm hands
of microorganism
6. Do the first maneuver. While
facing the mother, the examiner
Do determine its level, facing the head part of the
palpates the fundus using the
pregnant woman, palpate the fundus in order to define
fingertips to identify first the
which fetal is present in fundus.
fetal part that occupies the
fundus of the uterus.
7. Second Maneuver: Palpation
of the fetal back and small
parts. Still facing the mother,
the examiner’s palmar surface Applying the palm of the hands on either side of the
of the hand is placed on the one mother abdomen gentle but deep pressure is exerted to
side of the abdomen to steady locate the back of the fetus in relation to the right side
the uterus. While the other of the mother
hand palpates the other side in To determine if fetal back is facing the head part of the
a slightly circular motion of the mother, palpate to side to locate fetal back.
fingers from the top to lower
segment of the uterus to feel
the fetal outline.

8. The third maneuver: The

maneuver should next
determine with the right hand
To determine engagement and mobility of presenting
(if right handed) which fetal part
part still facing the head part of the mother grasp the
presenting over the inlet. This is
lower portion of the abdomen just above the symphysis.
to confirm the first maneuver.
Still facing the mother. This is Employing the thumb and fingers grasping the lower
done by gently grasping the portion of the maternal abdomen just above symphysis
lower pole of the uterus pubis to determine if the presenting part is engaged or
between the thumb and fingers not
and pressing in slightly. If the
presenting part is not engaged,
the next step is to determine
the attitude of the head.

9. Finally, the degree of descent

is estimated. To do this, the
examiner faces the woman’s
feet and uses both hands. The
sides of the uterus just below
the umbilical level are grasped Facing the mother’s feet, using the tips of the first three
snugly between the palms of fingers of each hand, making deep pressure in the
the hands; the fingers held close direction of the axis of the pelvic inlet to ascertain
together pointing downward presenting part of the engaged head.
and inwards. If the hands are
placed correctly, the first points Identifying the fetal position correctly
at the little fingers will be on Identifying which best place to hear the fetal heart tone.
level with the anterior iliac
spine and the outstretched Hearing the fetal heart tone and count.
thumbs will meet above the
level of the umbilicus. When the
presenting part has descended
deeply, only the small portion of
it may be outlined. Palpation of
the anterior shoulder will aid in
assessment of descent of the
vertex.
10. Able to auscultate the FHB To determine fetal pulse, and listen carefully for
by using Doppler or counting the pulse.
stethoscope, locate fundus.
Begin listening halfway between
 the fundus and the pubis. Work
outward in widening circles until
a beating sound is heard.
Compare the beating with the
maternal pulse. If it is different,
count beats for a full minute.

Documentation provides coordination of care for future

11. Chart
references

Total Score

Equivalent Grade

Signature of C.I.

Signature of Student

Breathing Exercises, Coughing and Splinting

PROCEDURE TO BE PERFORMED: Breathing Exercises, Coughing and Splinting

DEFINITION OF THE PROCEDURE:

-Diaphragmatic breathing or deep breathing is breathing that is done by contracting the diaphragm, a muscle
located horizontally between the thoracic cavity and abdominal cavity. Air enters the lungs; the chest does not
rise and the belly expands during this type of breathing. Diaphragmatic breathing is also known as scientifically
as eupnea, which is a natural and relaxed form of breathing in all mammals.

-Coughing is a forceful release of air from the lungs that can be heard. Coughing protects the respiratory system
by clearing it of irritants and secretions.

-Splint is defined as a rigid or flexible device that maintains in position a displaced or movable part, also used to
protect an injured part, or as a rigid or flexible material used to mobilized, or restrict motion in a part.

PURPOSES OF THE PROCEDURE:

Moving
- To maintain blood circulation
- To stimulate respiratory function
- To decrease stasis of gas in the intestine
- To facilitate early ambulation
Leg exercise
- To stimulate blood circulation, thereby preventing thrombophlebitis and thrombus formation.
Deep Breathing and coughing
- To facilitate lung aeration, thereby preventing atelectasis and pneumonia.
Splinting
- May reduce pain while coughing if the incision is near any of this muscles

EQUIPMENTS TO BE USED IN THE PROCEDURE:

- Pillow
- Teaching materials

Breathing Exercises, Coughing and Rationale 5 4 3 2 1

Splinting

1. Check the patient’s chart for the To be able to know and understand the previous
type of surgery and review the medical order before start the procedure
medical orders.
2. Gather the necessary supplies and To save time and effort
bring to the bedside stand or over bed
table.

3. Perform hand hygiene and put on To prevent the transmission of microorganism

PPE, if indicated.
To ensure the right procedure given to the patient
4. Identify the patient.
at a time.

5. Close curtains around bed and close To promote privacy

the door to the room, if possible.
To minimize embarrassment
Explain what you are going to do and
why you are going to do it to the
patient.
6. Identify the patient’s learning To promote health teaching regarding the
needs. Identify the patient’s level of procedure
knowledge regarding deep breathing
exercises, coughing, and splinting of
the incision. If the patient has had
surgery before, ask about this
experience.

7. Explain the rationale for performing To make sure that the patient will know and
deep breathing exercises, coughing understand the process of the procedure
and splinting of the incision.

8. Provide teaching about deep To promote breathing improvement of the patient

breathing exercises.

a. Assist or ask the patient to sit-up

Upright position allows increased diaphragmatic
(semi-or-high-Fowler’s position) and
excursion secondary to downward shift of internal
instruct the patient to place the palms
organs from cavity and this position allows client
of both hands along the lower
to feel movement of diaphragm, including a deep
anterior rib cage.
breath.
b. Instruct the patient to exhale gently
and completely.
Inhaling through the nose allows air to be filtered,
c. Instruct the patient to breathe in
warmed, and humidified. Holding breath lungs to
through the nose as deeply as
expand fully.
possible and hold breath for 3
seconds. Show expulsion of air frequently initiates the
coughing reflex, which facilitates expectoration of
d. Instruct the patient to exhale
mucus and prevents hyperventilation.
through the mouth, pursuing the lips
like when whistling.

e. Have the patient practice the
breathing exercise three times.
f. Instruct the patient that this
exercise should be performed every 1
to 2 hours for the first 24 hours after
surgery.
Performing exercise every three times to promote
airway clearance without overtiring the client
Inform the client about the expected frequency of
there exercise.

9. Provide teaching regarding Several cough are more effective than one single
coughing and splinting (providing cough at moving mucus up and out of the
support to the incision). respiratory tract.
a. Ask the patient to sit up (semi- Coughing uses abdominal and respiratory muscles
Fowler’s position) and apply a folded which may have been cut during surgery.
bath blanket or pillow against the part
of the body where the incision will be
(e.g., abdomen or chest).

b. Instruct the patient to inhale and

exhale through the nose three times.

c. Ask the patient to take a deep and

hold it for 3 seconds and then cough
out three short breaths.

d. Ask the patient to take a breath

through the mouth and strongly
cough again two times. Inform the client about the expected frequency of
these exercise
e. Instruct the patient that he or she
should perform these actions every 2
hours when awake after surgery.

10. Validate patient’s understanding To ensure that the patient understand the
of information. Ask the patient to give procedure and to be able to perform the
a return demonstration. Ask the procedure.
patient if he or she has any questions.
Encourage the patient to practice the
activities and ask questions, if
necessary.
11. Remove PPE, if used. Perform To avoid spread of infection and to prevent cross
hand hygiene. contamination

Total Score
Equivalent Grade

Signature of C.I.
Signature of Student

Collecting Specimens

PROCEDURE TO BE PERFORMED:
  Collecting a urine specimen
 Collecting stool specimen
 Collecting of Sputum specimen

DEFINITION OF THE PROCEDURE:

Urine specimen- is a procedure used to obtain a sample of urine from a patient. The sample is used for
diagnostic test.

Collecting Stool Specimen- is the process of obtaining a sample of a patient’s faces for diagnostic purposes.

Collecting of Sputum specimen- is a test to detect and identify bacteria or fungi that infect the lungs or
breathing passages. It is a thick fluid produced in the lungs and in the adjacent airways.

PURPOSES OF THE PROCEDURE:

 To determine the presence of microorganisms, the type of organism and the antibiotics to which the
organisms are sensitive

EQUIPMENTS TO BE USED IN THE PROCEDURE:

 Antiseptic towelette, such as providone-iodine

 Collection tubes
 Sterile cotton balls or 2x2 gauze pads
 Sterile lancet
 sterile gloves
 Hand towel or absorbent pad
 Slides
 Specimen identification label
In addition the nurse needs to obtain:
 Completed laboratory requisition form
 Urine receptacle, if the clients is not ambulatory
 Basin of warm water, soap, wash cloth, and towel for the non-ambulatory client

Collecting Specimens Rationale 5 4 3 2 1

1. Check for a written doctor’s order To be aware and understand the importance of
for such examination. accurate record keeping

2. Bring necessary equipment to the To save time and effort

bedside stand or over bed.

3. Perform hand hygiene and put on To avoid cross contamination and prevent spread
PPE, if indicated. of infection

4. Identify the patient. Explain the Assess the patient understanding,

procedure to the patient. If the patient
inform the patient of the reason for the
can perform the task without
procedure
assistance after instruction, leave the
container at bedside with instructions
to call the nurse as soon as specimen
is produced.
5. Check specimen label with the The sample should be label to avoid exchanging
patient’s identification bracelet. Label the specimen for patient safety
should include patient’s name and
to ensure the sample will give to the right patient.
identification number, time specimen
was collected, route of collection,
identification of the person obtaining
the sample, and any other information
 required by agency policy.

6. Close curtains around bed and close To provide client privacy

the door to the room, if possible.

7. Put on disposable gloves. Collect To avoid cross contamination

specimen. Close lid to container.

8. Remove gloves. Perform hand To prevent cross contamination

hygiene. To prevent spread of infection
To protect patient from adverse errors made due
9. Fill up laboratory request and bring to improperly labelled specimens, the laboratory
request and specimen to the demands that proper labelling criteria are always
laboratory. met.

For patient safety purposes.

Total Score
Equivalent Grade 

Signature of C.I.
Signature of Student

Providing Range of Motion (ROM) Exercises

PROCEDURE TO BE PERFORMED: PROVIDING RANGE OF MOTION

DEFINITION OF THE PROCEDURE: a device self-imposed or set to keep the body and mind trim.

Active ROM EXERCISE are isotonic (muscle tension is constant and the muscle shortens to produce muscle
contraction and active movement).

PASSIVE ROM EXERCISE- are those in which the nurse or therapist moves each of the client joints through its
complete range of motions.

ACTIVE- ASSISTIVE ROM EXERCISE- are those in which the client uses a stronger, opposite arm or leg to move
the joints of immobile limb.

PURPOSES OF THE PROCEDURE:

IN-HEALTH

 TO promote health by improving functioning of the circulatory system and lung

 To retain movements in joints and normal tone in the muscles controlling them
 To prevent stiffness of joint
 To decrease cholesterol level and low density lipo-protines
 To decrease body weight of obese person by increasing caloric expenditure
 To delay degenerative changes
 To improve flexibility and overall muscles strength and endurance

IN-SICKNESS- to prepare the patient for ambulation in:

  Orthopedic condition
 Deformity and fracture of extremities
 Cervical fracture
 Crutch walking
 Post-operative period
 To restore muscles function in case of disease, injuries and deformities
 To strengthen weak muscle and to restore balance after disease or injury of joint movement
 To promote physical mobility and improve gait
 To prevent deformity
 To improve blood supply
 To improve the functioning of lungs to expel secretion in case of post operative period and lung disorder
 To prevent constipation
 To reduce stress
 To prevent thrombus formation

EQUIPMENTS TO BE USED IN THE PROCEDURE:

 No equipment needed expect Gloves when body fluids is possible

 Bath blanket as needed
 Hospital bed

Providing Range of Motion (ROM) Rationale 5 4 3 2 1

Exercises

The nurse should consider any medical

1. Review the physician’s orders and
nursing plan of care for patient
activity. Identify any movement
limitations.
2. Perform hand hygiene and put on
PPE, if indicated.
contraindications for each client. To ensure the type
and amount of exercises are approved by the
physician or the physical therapist.
To identify the movement is to promote the joints
areas for exercise
To remove transient microorganism that might be
transmitted to the client.

3. Identify the patient. Explain the A client at ease and relaxed about exercising can
procedure to the patient. more actively take part in it.
4. Close curtains around bed and Promote privacy and Decreases embarrassment
close the door to the room, if
Place the bed at an appropriate to prevent muscle
possible. Place the bed at an
strain and discomfort for nurse.
appropriate and comfortable
working height, usually elbow height
or the caregiver. Adjust the head of
the bed to a flat position or as low as
the patient can tolerate.

5. Stand on the side of the bed To promote comfortable and to prevent muscle
where the joints are to be exercised. strain
Lower side rail on that side, if in
Provide systematic method to ensure that all body
place. Uncover only the limb to be
parts are exercised
used during the exercise.
6. Perform the exercises slowly and Provide exercise to the clients tolerance
gently, providing support by holding
the areas proximal and distal to the
joint. Repeat each exercise two to
five times, moving each joint in a
smooth and rhythmic manner. Stop
movement if the patient complains
of pain or if you meet resistance.

7. While performing the exercises, To optimize the performance of the movements

begin at the head and move down
To preserve muscle tone and joint flexibility
one side of the body at a time.
Encourage the patient to do as many
of these exercises by him-or herself
as possible.
8. Move the chin down to rest on To optimize the performance of the movements
the chest. Return the head to a
To prevent muscle tone and joint flexibility
normal upright position. Tilt the
head as far as possible toward each
shoulder.

9. Move the head from side to side, To optimize the performance of the movements
bringing the chin toward each
shoulder.
10. Start with the arm at the To prevent muscle tone and joints
patient’s side and lift the arm
forward to above the head. Return
the arm to the starting position at
the side of the body.

11. With the arm back at the Stretch muscles and keep the joint flexible
patient’s side, move the arm
laterally to an upright position above
the head, and then return it to the
original position. Move the arm
across the body as far as possible.
12. Raise the arm at the side until To stretch muscles and and keep joint flexible
the upper arm is in line with the
shoulder. Bend the elbow at a 90-
degree angle and move the forearm
upward and downward, then return
the arm to the side.

13. Bend the elbow and move the
lower arm and hand upward toward
the shoulder. Return the lower arm
and hand to the original position
while straightening the elbow.
14. Rotate the lower arm and hand
so the palm is up. Rotate the lower
arm and hand so the palm of the
hand is down.
Done to the amount of reps recommended to check
if the joint will react abnormally to the movement
or it helps the joint
To check if gliding joint and muscles present are
clearly function, it helps maintaining the
movements easily

15. Move the hand downward To ease the joint maintain the normal movements
toward the inner aspect of the with complication
forearm. Return the hand to a
It helps to detect any problems with the joints and
neutral position even with the
muscles.
forearm. Then move the dorsal
position of the hand backward as far
as possible.
16. Bend the fingers to make a fist, To maintain the joint and muscles normal
and then straighten them out. movements and to check any abnormalities
Spread the fingers apart and return
them back together. Touch the
thumb to each finger on the hand.

17. Extend the leg and lift it upward.
Return the leg to the original
position beside the other leg.
18. Lift the leg laterally away from
the patient’s body. Return the leg
back toward the other leg and try to
extend it beyond the midline.
To detect any abnormalities and problems in the
limb to improve the movements in the muscles and
joint
Exercise the movements of the joints and muscles
to help maintain functioning well

19. Turn the foot and leg toward the
other leg to rotate it internally. Turn
the foot and leg outward away from
the other leg to rotate it externally.
20. Bend the leg and bring the heel
toward the back of the leg. Return
the leg to a straight position.
to rotate the foot and leg it helps to relax and keep
the joint flexible
To detect any abnormalities and problems in the
hinge joint in the knee to induce the exercise
making the joint and muscles at an optimum state

21. At the ankle, move the foot up To check if the ankle joint are will functioning
and back until the toes are upright. without any soar or pain
Move the foot with the toes pointing
downward.
22. Turn the sole of the foot toward To check if the joint are functioning well in moving
the midline. Turn the sole of the foot toward the midline movement
outward.

23. Curl the toes downward, and To keep muscles and joint flexible
then straighten them out. Spread
the toes apart and bring them
together.
24. Repeat these exercises on the Passive exercises only help prevent contractures
other side of the body. Encourage and retard atrophy
the patient to do as many of these
exercises by him- or herself as
possible.

25. When finished, make sure the To promote client comfort and relax
patient is comfortable, with the side
rails up and the bed in the lowest
position.
26.  Remove gloves and any other To prevent cross contamination
PPE, if used perform hand hygiene. 

Total Score 
Equivalent Grade

Signature of C.I.
Signature of Student

POURING STERILE SOLUTION

PROCEDURE TO BE PERFORMED: POURING STERILE SOLUTION

DEFINITION OF THE PROCEDURE: is a microorganism free area

PURPOSES OF THE PROCEDURE:

 To ensure that sterile items remain sterile

 To create an environment that helps ensure the sterility of supplies and equipment and prevent transfer
of microorganism during sterile procedures.

EQUIPMENTS TO BE USED IN THE PROCEDURE:

 Flat work surface

 Sterile drape
 Sterile supplies: sterile gauze, sterile bash, solution, scissors, forceps
 Packaged sterile gloves

Pouring Sterile Solutions Rationale 5 4 3 2 1

1. Wipe the bottle cap with a tissue To avoid transferring of bacteria

solution or paper towel.
2. Loosen cap with thumb and index To avoid from spilling
finger.

3. Remove the cap with small finger and To maintain sterility of the solution and field
side of the palm. Hold the bottle with the
label upward.
4. Pour a small amount of solution away This ensure sterility of the solution
from the label into the sink or waste
container to cleanse tip of bottle.

5. Pour the needed amount of solution
into the provided container, catching the
last drop with the slightly twist.
6. Recap the bottle.
To avoid splash solution that might cause
contamination.
Keep solution in the bottle sterile and avoid use
of solution that passed expire

Total Score
Equivalent Grade

Signature of C.I.
Signature of Student